The Maryland Insurance Administration received the below comment letters following the recent Clean Claims Regulations Public Meetings.
200 St. Paul Place, Suite 2700
On behalf of the Maryland Hospital Association (MHA) and its member hospitals and health systems, thank you for the opportunity to comment on Maryland's clean claims and prompt payment regulations following the Maryland Insurance Administration's July 1 public meeting. MHA appreciates the Administration's review of these regulations and looks forward to participating in the Aug. 18 session.
Claims processing has changed significantly since these rules were last amended in 2017. Carriers increasingly rely on automated tools, payment integrity platforms, claim edits, and AI assisted review to process hospital claims. These tools can create efficiencies, but they also underscore the importance of having clear notices and a defined path to collect payment. MHA respectfully offers the following recommendations.
Under Insurance Article § 15-1005, a carrier must act within 30 days after receipt of a claim by either submitting payment or sending a notice stating why the claim is refused and what information is needed to correct any deficiencies. In practice, however, carriers use additional information requests or a generic “pending” status, which often results in claims being unresolved for extended periods with no justification or explanation. Hospitals are frequently unclear about what additional information is needed to correct the claim. As a result, a claim can remain pending indefinitely. These delays and lack of notice create a significant operational burden, undermine the purpose of the prompt payment statute.
MHA recommends closing this gap in two ways. First, "pending," "under review," and similar terminology should not be treated as a separate claim status that lets a carrier sidestep the 30-day framework. When a carrier needs additional information, it should be required to affirmatively notify the hospital, identify the specific claim and line item at issue, and state precisely what information is needed. Second, a claim should reach a clear endpoint rather than sitting in review indefinitely. If a hospital does not respond within a clearly stated timeframe, the carrier should be required to issue a final claim status notice rather than leave the claim pending indefinitely.
Maryland took an important step in 2025 by regulating the use of artificial intelligence, algorithms, and software tools in utilization review. Utilization review and prompt payment operate under different statutory frameworks and address different parts of the payer process. Utilization review focuses on whether a health care service is medically necessary, appropriate, or covered before, during, or after care is provided. Prompt payment, however, governs how a carrier must respond when a claim has been submitted.
Similar to the utilization review, artificial intelligence, algorithms, and software tools are also having a significant negative impact on the claims payment process. They create operational burdens for providers, forcing them to hire additional staff to manage growing volumes of unresolved claims. Hospitals report a sudden and substantial increase in the number of claim reviews per reviewer in recent years. The scale and pace of this increase raise concerns that AI or other automated systems are being used to review claims and inform payment decisions. Without greater transparency and stronger reporting requirements it is difficult to determine whether these systems are being used appropriately or are unnecessarily delaying payment of valid claims.
MHA recommends that MIA require carriers to provide clear notice when an automated tool materially contributes to one of these actions, including the basis for the action, the affected claim or line item, and the precise information needed to resolve the issue. MHA also recommends expanding aggregate claims data reporting to capture claims involving automated tools to assess any increase in instances of downcoding, reductions, and unresolved review statuses.
MHA strongly supports codifying the standard MIA set in its recent Cigna consent order and in Bulletin 26-9. Those actions make clear that a carrier may not unilaterally change a submitted code to a lower paying code. Instead, a carrier that questions a submitted code should use the prompt payment framework: pay the claim, deny or partially deny it with a specific reason, or request the specific information needed to resolve the issue. MHA requests that MIA codify this standard in the clean claims regulations and identify improper downcoding as a violation subject to penalty and corrective action.
COMAR 31.10.11.13 requires carriers that use auto codes to assess the validity of emergency department claims to disclose those codes to hospitals. The use of auto codes is in tension with Maryland’s prudent layperson standard. This standard requires that emergency claims be evaluated on the patient's presenting symptoms as they reasonably appeared at the time, not on the final diagnosis. An auto code, however, is a diagnosis code. By keying the emergency determination to a set of diagnoses, a carrier necessarily ties reimbursement to the final diagnosis rather than to the symptoms that brought the patient to the emergency department. An auto code alone, therefore, cannot establish whether the prudent layperson standard was met.
As carriers nonetheless use auto codes to evaluate ED claims, MHA recommends that carriers be required to disclose the clinical criteria supporting their ED auto codes in addition to the codes themselves. Requiring disclosure of the underlying criteria alongside the codes would allow hospitals to confirm that the prudent layperson standard was applied and to respond meaningfully when an emergency department claim is pending, reduced, denied, or subject to an additional information request. This would strengthen the existing disclosure requirement and help ensure that emergency department claims are evaluated in a manner consistent with the prudent layperson standard.
Section 15-1005 requires carriers to pay interest on clean claims not paid within 30 days of receipt at escalating monthly rates and to include that interest in any late payment, without the hospital having to request it. That interest obligation protects hospitals only if they can confirm it was met. In practice, however, hospitals often cannot determine whether the required interest was paid. When the accounting of interest is absent or unclear, interest owed by law goes unverified and uncollected, and systemic underpayment is difficult to detect.
MHA recommends that the Administration's regulations require remittance advice, which includes the information hospitals need to confirm compliance with § 15-1005, including payment of interest. The remittance advice should include the date the carrier received the claim, the date of payment, the amount paid or unpaid, and, for any late payment, a separate and itemized accounting of the interest paid, including the rate and the period on which it was calculated. Requiring carriers to identify and itemize interest is a straightforward improvement that reinforces an existing obligation on carriers. It does not change when interest is owed, only whether hospitals can see that it was paid correctly. Where standardized electronic remittance formats apply, carriers should provide any detail not captured in those formats through the accompanying notice. MHA also requests that failure to properly itemize required interest be identified as a violation subject to penalty under COMAR 31.10.23.01.
Finally, MHA encourages MIA to work with the Health Services Cost Review Commission (HSCRC) to evaluate the interaction of Maryland's prompt payment protections with HSCRC’s working capital differential program to ensure participating carriers are incentivized to make prompt payments and protect hospitals against the financial disruption that results from delayed payments. Under a working capital differential arrangement, a carrier that advances working capital to hospitals receives a discount on HSCRC-approved rates. Under the longstanding interpretation reflected in Bulletin 99-19, a payer that complies with regulations governing HSCRC’s working capital differential program is treated as having complied with the prompt payment rule for purposes of interest on past due payments. 1 The bulletin also preserves enforcement authority where a payer otherwise violates § 15-1005, refuses to pay a claim, or unreasonably delays payment. MHA encourages the agencies to reassess whether that interpretation continues to provide adequate incentives for prompt claim resolution.
1 See COMAR 10.37.10.26.
MHA appreciates MIA's work to modernize these regulations and welcomes the opportunity to contribute toward specific regulatory language.
MedChi, The Maryland State Medical Society
The Honorable Marie Grant
Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Re: Clean Claims Notice and Hearing
Dear Commissioner Grant:
On behalf of our client MedChi, The Maryland State Medical Society, and the patients we serve, we appreciate the opportunity to submit comments regarding Maryland’s clean claims law (Section 15- 1005 of the Insurance Article; COMAR 31.10-11.10-.15).
First and foremost, MedChi continues to have significant concerns regarding insurers' failure to pay claims within the timeframes required by Section 15-1005 of the Insurance Article. For example, CareFirst has acknowledged that it has been unable to process and pay claims in a timely manner due to an operational issue. While we recognize this operational issue, it does not relieve it of its statutory obligations. Physicians continue to report unpaid clean claims dating back several months, even back to November 2025, an issue MedChi has raised with the Maryland Insurance Administration. This issue must be resolved expeditiously across all lines of business, and, for those claims subject to Section 15-1005, interest payments must be made.
In addition, MedChi respectfully offers the following recommendations for regulatory consideration:
COMAR 31.10.11.11
Section B states that “[a] third-party may not request additional information if an attachment containing the same type of information was submitted with the claim pursuant to Regulation .10 of this chapter.” This section should be expanded to prohibit an insurer from requesting additional information when that information was previously submitted as part of the prior authorization process or otherwise provided to the insurer before the claim was filed. Requiring physicians to repeatedly submit the same documentation creates unnecessary administrative burden and contributes to delays in claims processing.
COMAR 31.10.11.12
Physicians are often unaware that a specific claim is subject to Maryland’s interest payment requirements because the enrollee is covered by a fully insured health plan. Under this regulation, physicians only receive acknowledgment of a claim “pursuant to a request for claim receipt verification by a health care practitioner.” Consideration should be given to requiring insurers to automatically send a receipt of verification that identifies whether the claim is subject to the protections of Maryland’s clean claims law, including the statutory interest provisions. Likewise, the remittance notice should indicate how many days late a claim is being paid and the amount of interest. Providing this information would enable physician practices to more effectively reconcile payments and verify compliance with Maryland law.
COMAR 31.10.11.14
Insurers are required to submit claims data to the Commissioner twice a year; however, under Section D that information is considered to be confidential commercial information. It is unclear why this data should be confidential. Similar to Maryland’s Appeals and Grievance law, aggregate claims performance data should be publicly available. Greater transparency would improve accountability, assist policymakers in evaluating compliance with Maryland’s clean claims law, and provide valuable information to physicians and the public. We encourage discussions regarding the removal of the confidentiality provision and the integration of the data into the Maryland Medical Claims Data Base, including the development of public reporting mechanisms.
Thank you for considering these comments. MedChi looks forward to continuing to work with the Maryland Insurance Administration to ensure timely claims payment, reduce unnecessary administrative burdens on physicians, and protect access to care for Maryland patients.
Sincerely,
Danna L. Kauffman, Esquire
On Behalf of MedChi
APTA Maryland
July 15, 2026
The Honorable Marie Grant, Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Re: Impact of Delayed Payment of Clean Claims on Maryland Physical Therapy Practices
Dear Commissioner Grant:
On behalf of Maryland physical therapy providers, the American Physical Therapy Association of Maryland (APTAMD), we are writing to express serious concerns regarding the increasing frequency of delayed payment of clean claims by health plans and Medicaid managed care organizations operating within Maryland. We are thankful for your commitment to bring together stakeholders to identify the challenges impacting prompt payment of clean claims. We appreciate MIA hosting public hearings and requesting input from providers as MIA works towards solutions in collaboration with the Adverse Decision Workgroup sessions.
APTAMD acknowledges Maryland's Prompt Pay Law, codified in Insurance Article §15-1005, applies to certain health insurance and managed care payers that operate in the state and handle claims for health coverage. Requiring these carriers to either pay a clean claim or provide a written explanation of the claim's status within 30 days of receipt, and if not paid within 30 days interest payments are required to be paid. The law further requires carriers to specify any information necessary to render a claim "clean", which triggers prompt payment. 1 2
Despite this regulation, physical therapy practices accepting patients from carriers required to comply are experiencing significant payment delays despite submitting complete and accurate claims. These delays create substantial operational and financial burdens on providers who are already facing rising labor, technology, compliance, and administrative costs. Also, these delays are not unique to the carriers but occur with employer-funded and ERISA plans as well.
APTAMD surveyed our membership to gather data regarding carriers’ clean claims payment behavior across the state. APTAMD’s preliminary data from 9 group practices are listed in Table 1. Although 9 practices responded to date, the 9 practices represent thousands of claims submitted on an annualized basis.
Table 1: Clean claims payment delays by payer
(% of respondents reporting payment beyond 15 days)
Payer | 0–15 days | 15–30 days | >30 days | % delayed >15 days
|
Medicare Advantage | 0% | 50% | 50% | 100% |
Tricare/VA | 12.5% | 37.5% | 50% | 87.5%
|
CareFirst | 12.5% | 50% | 37.5% | 87.5% |
Medicaid | 22.2% | 44.4% | 33.3% | 77.8% |
UnitedHealth Group | 25% | 62.5% | 12.5% | 75% |
Medicare | 55.6% | 22.2% | 22.2% | 44.4% |
Aetna | 62.5% | 25% | 12.5% | 37.5% |
Physical therapy practices operate on relatively narrow margins and rely heavily on predictable cash flow to maintain patient access to care. When clean claims remain unpaid beyond statutory timelines, practices must absorb the costs associated with clinician salaries, employee benefits, facility expenses, electronic health record systems, compliance programs, and other overhead expenses without the expected reimbursement. The result is increased financial strain, reduced resources available for patient care, and difficulty recruiting and retaining qualified rehabilitation professionals. Also, if the practice is not paid timely or the claims are suspended for no reason, the financial responsibility shifts to the patient to incur the non-payment costs.
Moreover, delayed reimbursement creates unnecessary administrative costs. Staff members must devote considerable time to investigating claim status, resubmitting documentation, responding to repeated requests for information previously provided, filing appeals, and contacting payer representatives. These activities divert resources away from patient care and increase healthcare costs without improving quality or outcomes.
Of particular concern is the frequency with which providers are asked to submit additional documentation long after a claim has been filed, even when the original submission met all stated clean claim requirements. Such requests appear inconsistent with the intent of Maryland's clean claims requirements and undermine the purpose of the Prompt Pay statute, which is designed to ensure timely adjudication and payment of claims. 3 4
The impact extends beyond providers and ultimately affects Maryland beneficiaries. Cash-flow instability can force practices to limit participation with certain payers, delay hiring additional clinicians, reduce service availability, or postpone investments in patient care infrastructure. In underserved and rural communities, these pressures may threaten access to medically necessary physical therapy services for Medicaid recipients, older adults, children with special needs, and individuals with chronic conditions.
We respectfully request that the Maryland Insurance Administration:
1. Increase oversight and auditing of carrier compliance with Maryland's Prompt Pay requirements.
2. Establish a standardized manner to evaluate patterns of repeated requests for documentation on otherwise clean claims which are not in compliance with regulations.
3. Strengthen enforcement actions and/or provide resources to consumers and providers how to follow-up when carriers fail to comply with statutory payment timelines.
4. Increase transparency by publishing payer-specific Prompt Pay compliance data and complaint trends. APTAMD acknowledges denials, adverse decisions, clean claims, and overturn rates are published, but not Clean Claims data processing.
5. Engage providers and professional associations in discussions regarding barriers to timely claim adjudication.
6. Ensure that interest penalties for late payments are consistently applied when required by law when carriers are out of compliance with prompt payment. Physical therapy practices should not have to assume the administrative burden to track down interest payments, file a complaint with MIA, and/or report to State AG before appropriate action is taken.
7. Improve educational resources on the MIA website to assist providers and consumers how to file grievances for carriers not under direct oversight of the MIA, such as reporting to DOH, MHCC, and State Attorney General.
Maryland physical therapists are committed to providing high-quality, cost-effective care that improves function, reduces disability, and helps avoid more expensive medical intervention leading to downstream cost savings. Timely reimbursement is essential to sustaining that mission and preserving patient access to rehabilitation services throughout the state.
We appreciate your attention to this important matter and welcome the opportunity to discuss these concerns further. Thank you for your continued efforts to protect Maryland healthcare consumers and ensure compliance with Maryland insurance laws.
Respectfully, Roy J Film
APTA Maryland President
Zeeshan Bhimani
APTA Maryland
Director for Reimbursement
Cc. Barbara Brocato & Dan Shattuck, Brocato & Shattuck Consulting
1 https://health.maryland.gov/mmcp/provider/Documents/application-addenda/All-Provider-Enrollment-Types-List.pdf
2 https://www.careprecise.com/provider-counts/maryland-healthcare-provider-counts.htm
3 https://health.maryland.gov/mmcp/provider/Documents/application-addenda/All-Provider-Enrollment-Types-List.pdf
4 https://health.maryland.gov/mmcp/Pages/Provider-Information.aspx
Maryland Community Health System
To: Maryland Insurance Administration
From: Salliann Alborn, CEO
Subject: Comments on Maryland Insurance Administration’s Clean Claims Regulations
Date: July 15, 2026
Maryland Community Health System (MCHS) appreciates the Maryland Insurance Administration’s (MIA) efforts to promote timely, accurate, and transparent claims processing. MCHS is a Health Center Controlled Network of federally qualified health centers (FQHCs) providing primary medical, behavioral health, and dental care to underserved communities across Maryland. The clean claims regulations provide an important framework for ensuring that federally qualified health centers (FQHCs) are reimbursed appropriately and that payors maintain reasonable processes for reviewing claims.
During the July 1st meeting, the MIA provided a brief history of the current regulations (COMAR 31.10.11.10 through 31.10.11.14) as well as an overview of the statutory authority under Insurance Article §§15-1003 through 15-1005. At the end of the presentation the MIA posed four questions for stakeholders to comment on:
- Which provisions of regulations are outdated, and how should they be updated? • Does the list for attachments to be considered a clean claim require updating?
- Does the list of permissible categories of disputed claims for which additional information may be requested require updating? • Should the MIA resume issuing a Clean Claims Data Report with de-identified and aggregated data?
FQHCs operate as safety-net providers delivering integrated, team-based care that includes primary medical care, behavioral health services, dental care, enabling services, care coordination, and other supportive services. FQHC reimbursement is also governed by specialized payment methodologies, including the Medicare and Medicaid Prospective Payment System (PPS) structures, rather than traditional fee-for-service reimbursement models. As a result, claims-processing requirements developed primarily around individual professional services or procedural billing do not always align with FQHC operations. We recognize that certain Medicare and Medicaid reimbursement requirements may fall outside the MIA’s direct jurisdiction. Nevertheless, those payment methodologies shape FQHC billing operations, and the clean-claims regulations should account for those operational realities where MIA has authority. Updating certain part of COMAR 31.10.11.10–31.10.11.14 would reduce unnecessary administrative burden while maintaining appropriate safeguards against improper billing and fraud.
Which provisions of regulations are outdated, and how should they be updated? (COMAR 31.10.11.12 — Receipt of a Claim) The claim-receipt provisions should be modernized to reflect the current electronic claims practices as well as to algin with how Maryland has moved to updated prior authorization and appeals and grievances processes. Currently, FQHCs submit the vast majority of claims electronically through payor portals. The existing regulations focus on mailed claims, courier delivery, and batch receipt processes and do not fully address modern claims submission practices.
The regulation should require payors to provide timely electronic confirmation of claim receipt, including acknowledgment that the claim was received, accepted, or rejected. Once a claim has been successfully transmitted and accepted by a clearinghouse or payor system, the claim should be considered received for purposes of applicable payment deadlines. Providers should not bear the burden of disputes regarding internal payor processing failures after electronic acceptance has occurred. Similar to the prior authorization statute, the regulation should also require payors to provide accessible claim status information, including claim tracking identifiers, processing status, and reasons for delays or rejection.
COMAR 31.10.11.10 should also be modernized to replace outdated references to the HCFA Form 1500 and UB-92 with the current CMS-1500 and UB-04/CMS-1450 claim forms, as applicable. The regulation should recognize current HIPAA-compliant electronic transaction standards for professional, institutional, and dental claims, including applicable successor forms and standards. To prevent future obsolescence, the MIA should recognize federally adopted successor forms and transaction standards while preserving uniformity and prohibiting payors from requiring proprietary claim forms, data elements, or attachments beyond those authorized by law or regulation.
Does the list for attachments to be considered a clean claim require updating? (COMAR 31.10.11.10 — Attachments to Uniform Claims Forms) The current attachment requirements under COMAR 31.10.11.10 is primarily focus on procedure-based claims, including requirements involving operative reports, or anesthesia records. While these requirements may be appropriate in some circumstances, they do not fully reflect the encounter-based and integrated care model utilized by FQHCs. FQHC claims could represent comprehensive patient encounters involving multiple services rather than a single isolated procedure.
The regulation should be updated to establish that payors may not routinely require medical records, treatment plans, or other attachments for FQHC claims unless the request is related to a specific, documented issue involving payment, coverage, coding, medical necessity, or fraud. Consistent submission of clinical records with every FQHC claim creates significant administrative burden, and increases costs, without necessarily improving claims accuracy. The regulation should also expressly prohibit blanket or repetitive documentation requests and encourage payors to use targeted audits, provider education, and corrective action processes when additional review is necessary.
Does the list of permissible categories of disputed claims for which additional information may be requested require updating? (COMAR 31.10.11.11 — Additional Information) Yes, COMAR 31.10.11.11 provides important protections against inappropriate claim delays; however, additional safeguards are needed to prevent broad or nonspecific documentation requests from becoming a mechanism for delaying payment, a tactic MCHS believes already occurs today. FQHCs frequently experience claim delays related to payor-specific interpretations of billing requirements, authorization processes, and provider enrollment issues.
The regulation should require payors requesting additional information to identify with specificity the claim element in question, the reason the information is necessary, the applicable regulatory or contractual basis for the request, and how the requested information will affect claim adjudication. Additionally, the MIA should consider revising this regulation to shift the burden by presuming that claims are clean unless the payor identifies a specific deficiency. This approach would preserve the payor's authority to review claims while preventing unnecessary delays resulting from generalized or non-specific requests for additional information. The regulation should also prohibit payors from requesting information that has already been provided unless the payor identifies a material deficiency in the previously submitted documentation.
Should the MIA resume issuing a Clean Claims Data Report with de-identified and aggregated data? (COMAR 31.10.11.14 — Claims Data Filing) Yes, MCHS strongly supports resuming publication of a de-identified and aggregated Clean Claims Data Report. The current claims-data reporting requirements provide important oversight but do not capture the specific challenges faced by FQHCs. Reporting focused solely on overall clean claims rates, additional information requests, and payment compliance does not adequately identify whether claims-processing practices create disproportionate administrative burdens for certain provider types or certain care settings.
The regulation should require claims reporting to include provider-type specific data, and specific care setting data, which would include FQHCs. Payors should report information regarding claims volume, percentage of clean claims paid within the statutory timeframe, average time to payment, frequency of documentation requests, claims suspended for review, denial categories, and appeal outcomes. These additional data elements would allow the MIA to identify trends, monitor whether payors are applying appropriate claims-processing standards, and evaluate whether administrative practices are creating barriers to the financial stability of safety-net providers.
Thank you again for the opportunity to submit these comments. If we can provide any additional information, please contact me at
[email protected] or our policy consultants, Robyn Elliott and Michael Paddy at
[email protected] and
[email protected].
Maryland Podiatric Medical Association
The Adams Building, Suite 301
600 Baltimore Ave.
Towson, MD 21204
August 31, 2026
Mr. Matthew Weiss
Manager of Health Policy Initiatives
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Re: Clean-Claims-Public Meeting October 27, 2026
Dear Mr. Weiss,
On behalf of the officers, Board of Directors, Insurance Committee, and members of the Maryland Podiatric Medical Association (MPMA), we write to provide input ahead of October 27, 2026, public meeting on proposed revisions to COMAR 31.10.11 governing clean claims submission and processing.
MPMA members have consistently experienced two specific problems with current claim adjudication practices that we believe the proposed regulations should address directly. This issue has been mostly pronounced with CareFirst.
Many claims are denied outright with no request for additional documentation, even when the claim and medical record support the services billed and is in line with the insurance company's medical policies as well as NCCI edits. This is particularly concerning when carriers deny services reported with Modifiers 25 and 59, which are used to identify separately reportable services performed during the same encounter. Rather than providing a simple mechanism for the provider to submit supporting documentation for prompt review, these claims may be denied outright, forcing providers into an appeal process that frequently takes four to six months to resolve. This creates substantial administrative burden, delays appropriate reimbursement, and, in many cases, can disrupt patient treatment.
Patients who qualify for medically necessary at-risk foot care are generally seen on a recurring basis for the same or similar services because their underlying medical conditions and risk factors persist. When a claim for these services is denied and subsequently overturned on appeal, the same services for the same patient and qualifying diagnoses are frequently denied again at the patient's next medically necessary visit. Providers are then forced to repeat the entire appeal process despite the carrier having already reviewed the documentation and determined that the prior claim was payable.
A similar pattern occurs with Modifier 25. Providers may repeatedly submit documentation on appeal demonstrating that they performed and documented a significant, separately identifiable evaluation and management service in addition to a procedure performed at the same encounter. Even after the carrier reviews that documentation and repeatedly overturns the denials, subsequent claims from the same provider using Modifier 25 may continue to be denied, requiring the provider to repeatedly prove through individual appeals that the separately identifiable services billed were performed and appropriately documented. This recurring denial-and-appeal cycle creates unnecessary administrative burden and delays payment for services that the carrier has repeatedly determined on appeal were properly reported.
Regarding CareFirst specifically, appeals and supporting documentation is sent via the US Postal service rather than via an electronic portal or even a fax service. This creates a significant delay, makes tracking very difficult, even with return request receipts, and adds a layer of complexity and delay that is unnecessary and inconsistent with modern technology. Additionally, clean claims that are denied incorrectly and go through a prolonged review process are often paid several months later without interest.
We respectfully request that the draft regulations to be presented on October 27 address:
1. A requirement that, prior to denying a claim based on insufficient documentation or information necessary to determine coverage or medical necessity, the carrier notify providers and give them the opportunity to submit the requested documentation directly through either the carrier's secure electronic provider portal or a designated facsimile number. The carrier should acknowledge receipt of the documentation and complete its review and adjudication of the claim within seven (7) calendar days of receipt. A provider should not be required to initiate a formal appeal solely for the carrier to review documentation supporting the original claim, particularly when the records are consistent with the carrier's medical policy and the claims are coded following proper NCCI edits.
2. Once a carrier has overturned a denial on appeal and determined that recurring at-risk foot care is medically necessary for a patient, subsequent claims for the same patient, services, and qualifying conditions should not be denied for the same reason unless there has been a material change in the patient's clinical status or eligibility for the services.
Similarly, when a provider has repeatedly demonstrated through successful appeals that services reported with both Modifiers 25 and 59 were separately identifiable, performed, and appropriately documented, the carrier should not continue to systematically deny subsequent Modifier 25 and 59 claims from that provider solely to require the same issue to be proven through repeated individual appeals.
3. Reporting of carrier-level denial and appeal-overturn rates to MIA to support enforcement.
4. A defined, shortened appeal review timeline, with interest or penalty accrual for claims adjudicated late once overturned.
We appreciate the MIA's continued engagement with stakeholders on this issue and look forward to participating in the October 27th meeting. We would welcome the opportunity to discuss these concerns further before the draft regulations are finalized.
Sincerely,
Priya Parthasarathy, DPM
MPMA President
Maryland Hospital Association
6820 Deerpath Road
Elkridge, MD 21075
Sept. 4, 2026
Marie Grant
Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, Maryland 21202
Re: MHA Responses to Questions from the Aug. 18, 2026 Clean Claims Public Meeting
Dear Commissioner Grant:
On behalf of the Maryland Hospital Association (MHA) and its member hospitals and health systems, thank you for the opportunity to provide additional comments regarding potential revisions to Maryland’s clean claims regulations following the Maryland Insurance Administration’s Aug.18 public meeting.
Timely and predictable claims payment supports hospitals’ ability to maintain access to the services patients and communities rely on. Unnecessary delays and administrative burdens consume resources that could otherwise support clinical staff and patient care.
MHA recommends updates that would make the claims process more transparent, reliable, and timely for both providers and carriers. These include appropriate oversight of automated decisions, dependable electronic submission and tracking, clear documentation requirements, review of emergency claims based on presenting symptoms, and reciprocal deadlines that bring claims to resolution.
At its core, the clean claims process should be simple, transparent, and reliable. Carriers should clearly identify the information needed to adjudicate a claim, provide dependable electronic methods for submitting that information, confirm receipt, explain their determinations, and resolve claims within required timeframes. Hospitals should not have to search across multiple systems to determine what is being requested, resubmit records because a carrier failed to track or associate them with the claim, or pursue claim-by-claim appeals when the same carrier issue affects multiple claims. Technology should improve the process—not create new barriers, reduce accountability, or allow claims to be delayed, reduced, or denied without meaningful review.
MHA offers the following responses to questions raised at the Aug. 18 meeting for your consideration:
1. Should the regulations be updated to align with current technological advancements in claim processing? If yes, what updates should be made?
Yes. The regulations should be updated to reflect the increasing use of automated rules, claims-review software, algorithms, artificial intelligence, and other technology in claim processing. These tools may improve efficiency, but they should be subject to clear standards to ensure they make the claims process faster, more transparent, and more reliable—not more burdensome for providers or increasing unexplained delays, reductions, or denials.
The regulations should require carriers to disclose when an automated tool materially contributes to a denial, reduction, inquiry, or other action that delays resolution of a claim. The regulations should require meaningful review by a qualified individual when a provider disputes an initial determination. Automated tools should not be the final authority on disputed claims, and carriers should remain responsible for decisions produced or informed by their systems.
Carriers should be required to clearly explain the reason a claim was not approved, the criteria applied in making the determination, and what the provider must do to resolve the issue. When a technical issue affects multiple claims from the same provider, carriers should be required to notify the provider of the issue and allow all affected claims to be reprocessed without requiring separate appeals for each claim. These communications should be detailed enough for providers to understand and address the problem.
The regulations should also establish clear timeframes for carriers to respond to claim submissions, appeals, and requests for information so technology supports timely resolution rather than prolonged pending status.
2. Should the regulations be updated to align with current technological advancements in claim submission and receipt, including verification of standard data elements, attachments, and confirmation of receipt? If yes, what updates should be made?
Yes. The regulations should be updated to reflect modern electronic claim submission and receipt processes and should establish consistent minimum standards across carriers. Claim submission requirements, attachment capabilities, data-element verification, receipt confirmation, and claim-status tracking should be standardized to the fullest extent possible so technology improves the process rather than creating carrier-specific administrative burdens.
Providers should have reliable electronic methods to submit original claims, corrected claims, appeals, reconsideration requests, and supporting documentation, including medical records, itemized bills, and other attachments when needed. Carriers should be permitted to use clearinghouses, provider portals, or other electronic systems, but each system should be secure, capable of accepting complete records and large files, and able to confirm that submissions were received, associated with the correct claim, and available to the person reviewing the claim. Requiring carriers to accept electronic attachments should not mean hospitals must submit medical records with every claim.
The regulations should require clear electronic verification of standard claim data elements. Carriers should identify missing or invalid information within a defined period, such as one to three business days, and distinguish technical or data errors from acceptance of the claim for adjudication. Electronic notices should clearly identify whether the carrier is acknowledging receipt, accepting the claim for review, rejecting the claim because of a technical or data error, or requesting additional information.
Each electronic notice should include the date and time, a tracking number, the claim status, and any action the provider must take. Carriers also should maintain an accessible record showing when claims, attachments, notices, and provider responses were sent and received, and should provide real-time or near-real-time claim status information. Consistent receipt and tracking standards are necessary to ensure that electronic submission actually supports timely claim resolution.
3. What specific documentation do carriers require when submitting a claim, and how do providers know in advance what documentation may be needed for efficient adjudication?
Documentation requirements vary significantly by carrier, service, and claim. Commonly requested documentation includes medical records, triage and nursing assessments, physician documentation, diagnostic results, itemized bills, operative reports, authorization records, discharge summaries, primary-payer explanations of benefits, coordination-of-benefits information, and documentation supporting medical necessity.
Providers generally do not know in advance with certainty what specific documentation a carrier will require for efficient adjudication. They often learn only through denial notices, provider manuals, portal messages, past experience, or repeated disputes. In some cases, carrier requests do not clearly identify the specific portion of the record needed or explain why the information is necessary. Hospitals also report broad or duplicative requests, including requests triggered by claim value, requests for complete medical records when limited documentation would be sufficient, and requests for information about unrelated services.
The regulations should be updated to give providers clearer advance notice of documentation requirements. Carriers should maintain clear and publicly accessible policies explaining documentation requirements by type of service, criteria used to determine medical necessity, circumstances likely to require medical records or other documentation, and the methods for submitting those materials. If a carrier regularly requires a particular permissible document for a type of claim, the carrier should tell hospitals in advance so the document can be submitted with the initial claim rather than requested only after payment has been delayed or denied.
At the same time, advance notice should not expand what carriers are permitted to require. Carriers should not impose additional or undisclosed requirements beyond those permitted by regulation. When additional information is needed, each request should identify the claim and affected line item, state the precise information needed, explain why it is necessary and how it relates to the carrier’s decision, provide the submission method and deadline, and avoid demanding an entire medical record when a limited portion would resolve the issue. Carriers also should not request information already submitted or available through prior authorization, concurrent review, or a prior claim submission unless they provide a documented reason.
4. What further information should third-party payors be permitted to request when there is a reasonable belief that an emergency services claim may not satisfy the criteria under Health-General Article § 19-701(e)? Should providers be required to attach a list of presenting symptoms to the original claim?
Third-party payors should be permitted to request only the additional information reasonably necessary to evaluate whether the claim satisfies Maryland’s prudent layperson standard. Carriers already receive coded information about the patient’s signs or presenting symptoms with the original emergency department claim. Providers therefore should not be required to attach a separate list of presenting symptoms to every original claim.
If a carrier reviews the claim information and has a reasonable, claim-specific basis to question whether the emergency services criteria are met, the carrier may request targeted portions of the medical record needed to answer that question. Depending on the issue, relevant information may include the chief complaint, triage assessment, initial vital signs, acuity level, initial provider assessment, and diagnostic information available when treatment decisions were made. The request should identify the specific question being evaluated, explain why the information is necessary, and be limited to the relevant portions of the record. A complete medical record should be requested only when the carrier explains why more targeted information would be insufficient.
Furthermore, carrier auto-code lists should not be treated as the exclusive definition of an emergency. Those lists may help identify claims for automatic payment, but Maryland’s prudent layperson standard requires consideration of the patient’s symptoms as they reasonably appeared when care was sought, not whether a particular diagnosis code appears on a carrier’s list.
Finally, providers should not be required to attach a list of presenting symptoms to the original claim. That requirement would duplicate information already reported through diagnosis and symptom codes, create additional administrative burden, and risk turning routine emergency claims into documentation-heavy submissions. Instead, carriers should use the information already available on the claim and request additional, targeted documentation only when there is a specific reason to do so.
5. Should providers be required to respond to requests for additional information within a set period, such as 30 days, and should carriers then issue a final determination based on the information originally submitted if the provider does not respond?
Yes. The regulations should establish a 30-day provider response deadline and enforce the existing 30-day carrier deadline, so both parties have clear responsibilities, and every claim reaches a final resolution.
When a provider submits a claim, the carrier must either pay it or notify the provider within 30 days as to why all or part of the claim is not being paid, including any specific additional information needed. The hospital must then locate and submit the requested records or other documentation. Once that information is received, the carrier must complete its review and, within 30 days, pay the claim or issue a full or partial denial.
During this process, carriers may describe a claim as “pending,” “under review,” or “awaiting information.” Unfortunately, hospitals report that claims may remain in this unresolved status for 60, 90, or 120 days or longer, including after the requested records have been submitted. The regulations should establish a 30-day provider response deadline and enforce the existing 30-day carrier deadline, so both parties have clear expectations. The provider’s 30-day period should begin upon confirmed receipt of a clear request for more information. Reasonable extensions should be granted for complex or voluminous requests or circumstances outside the provider’s control.
Enforcement
Regulations are only impactful to the extent they are enforced. Any regulations that result from this process must ensure that violations can be identified and corrected. Repeated or systemic violations should be subject to appropriate penalties. We also respectfully ask MIA to enforce the existing requirement that interest be included automatically with late payments of clean claims. Carriers should also remain responsible for the actions of their vendors and automated systems.
Conclusion
These recommendations would create a clear path from claim submission to final resolution.
Technology should make claims review more efficient, allowing for clear and timely communication. It should not multiply the number of unresolved claims. Well defined regulatory requirements will improve the claims process, enhance transparency, and conserve resources for patient care.
MHA appreciates MIA’s efforts to modernize Maryland’s clean claims regulations and for this opportunity to comment. We look forward to continuing to work with you on this important issue.
Sincerely,
Andrew Nicklas
Senior Vice President, Government Affairs & Policy
General Counsel
SMWK - Schwartz Metz Wise Kauffman
20 West Street
Annapolis, MD 21401
September 2, 2026
The Honorable Marie Grant
Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Re: Clean Claims Notice and Hearing
Dear Commissioner Grant:
On behalf of our client MedChi, The Maryland State Medical Society, and the patients we serve, we appreciate the opportunity to submit additional comments and recommendations regarding Maryland’s Clean Claims Law (Section 15-1005 of the Insurance Article; COMAR 31.10-11.10-.15).
A top priority for MedChi remains ensuring physicians receive timely, accurate payments, especially given recent issues with CareFirst, as noted in our previous letter. While payment issues appear to have improved, physicians continue to report unpaid clean claims dating back several months, even to November 2025. Our member physicians have also told MedChi that many claims routinely remain in adjudicated status as “pending / in process and waiting for final approval” for weeks and are not processed until the physician calls or sends an inquiry.
In addition to our previous recommendations below, MedChi raises additional concerns and recommendations focused on stronger enforcement to ensure compliance with Maryland’s Clean Claims Law.
Currently, late payments on clean claims accrue at the rate of - 1.5% interest from the 31st day through the 60th day; 2% from the 61st day through the 120th day; and 2.5% after the 120th day. These interest payment amounts are too low and haven’t been updated in decades. MedChi recommends an examination to determine a more appropriate interest amount (§ 15-1005(g)). Again, we reiterate our recommendation below that an insurer should be required to indicate the amount of interest being paid separately from the payment of the actual clean claim. This will hold the insurer more accountable and allow physicians to track claim payments.
Likewise, the penalties in § 15-1005(h) are inconsequential. Under this section of the law, an insurer, nonprofit health service plan, HMO, or ASO that violates Maryland’s Clean Claims law is subject to a fine not exceeding $500 for each violation that is arbitrary and capricious. In addition, the Maryland Insurance Administration (MIA) can apply the penalties in § 4-113(d) for violations committed with a frequency that indicates a general business practice. Section 4-113(d) authorizes a penalty of not less than $100 but not more than $125,000 for each violation and may require a carrier to make restitution to any person who has suffered financial injury because of the violation. First, a $500 fine can be viewed as simply the “cost of doing business,” especially given the fact that it is difficult for health care providers to track interest payments and the high standard of “arbitrary and capricious.” In addition, it is unclear how “a general business practice” is applied.
On that note, § 4-113(b)(5) states that “[t]he Commissioner may deny a certificate of authority to an applicant or, subject to the hearing provisions of Title 2 of this article, refuse to renew, suspend, or revoke a certificate of authority if the applicant or holder of the certificate of authority refuses or delays payments of amounts due claimants without just cause.” Subsection (d) then authorizes the Commissioner to issue a penalty rather than act against the certificate holder. From MedChi’s reading, this is not limited to a particular health plan but to the “doing business” in Maryland. Therefore, MedChi strongly encourages the MIA to use this authority to take appropriate action when enforcing the Clean Claims Law.
Thank you for considering these comments. MedChi looks forward to continuing to work with the MIA to ensure timely claims payment, reduce unnecessary administrative burdens on physicians, and protect access to care for Maryland patients.
Sincerely,
Danna L. Kauffman, Esquire
On Behalf of MedChi
Submitted on July 15, 2026
COMAR 31.10.11.11
Section B states that “[a] third-party may not request additional information if an attachment containing the same type of information was submitted with the claim pursuant to Regulation .10 of this chapter.” This section should be expanded to prohibit an insurer from requesting additional information when that information was previously submitted as part of the prior authorization process or otherwise provided to the insurer before the claim was filed. Requiring physicians to repeatedly submit the same documentation creates unnecessary administrative burden and contributes to delays in claims processing.
COMAR 31.10.11.12
Physicians are often unaware that a specific claim is subject to Maryland’s interest payment requirements because the enrollee is covered by a fully insured health plan. Under this regulation, physicians only receive acknowledgment of a claim “pursuant to a request for claim receipt verification by a health care practitioner.” Consideration should be given to requiring insurers to automatically send a receipt of verification that identifies whether the claim is subject to the protections of Maryland’s clean claims law, including the statutory interest provisions. Likewise, the remittance notice should indicate how many days late a claim is being paid and the amount of interest. Providing this information would enable physician practices to more effectively reconcile payments and verify compliance with Maryland law.
COMAR 31.10.11.14
Insurers are required to submit claims data to the Commissioner twice a year; however, under Section D that information is considered to be confidential commercial information. It is unclear why this data should be confidential. Similar to Maryland’s Appeals and Grievance law, aggregate claims performance data should be publicly available. Greater transparency would improve accountability, assist policymakers in evaluating compliance with Maryland’s clean claims law, and provide valuable information to physicians and the public. We encourage discussions regarding the removal of the confidentiality provision and the integration of the data into the Maryland Medical Claims Data Base, including the development of public reporting mechanisms.
APTA Maryland
August 31, 2026
The Honorable Marie Grant, Commissioner
Maryland Insurance Administration
200 St. Paul Place, Suite 2700
Baltimore, MD 21202
Re: Public Comments on Clean Claims Delays and Needed Regulatory Updates
Dear Commissioner Grant:
APTAMD appreciates the opportunity to provide additional comments following the August 18th Clean Claims Public meeting. Maryland physical therapy practices continue to experience significant delays in the payment of clean claims, creating financial strain and administrative burden that directly affect patient access.
As noted in our July submission, providers report that “clean claims remain unpaid beyond statutory timelines” and that staff must “devote considerable time to investigating claim status, resubmitting documentation, responding to repeated requests for information previously provided.” These issues persist across fully insured, Medicaid MCO, Medicare Advantage, and ERISA/ASO plans.
APTAMD offers the following recommendations, including a comparison to Alabama’s clean claims statutei, which could provide some useful ideas for enforceability and transparency.
1. Clarify and Operationalize the Clean Claim Definition
- Require carriers to specify the exact missing or invalid data element when rejecting a claim.
- Track initial submissions, resubmissions, and denial reasons.
- Report to MIA the percentage of claims initially denied for “missing data” that are later paid without changes.
- Alabama Comparison: Alabama’s §27-1-17 requires carriers to provide notice of missing information within 30 days and pay or deny within 21 days after receiving that information — a clear operational standard Maryland could mirror.
- Alabama contains language on Coordination of Benefits prompt payment.
2. Enforce Automated Interest Payments
- Require automatic calculation and itemization of interest when claims exceed statutory prompt payment timelines per Maryland’s Insurance Article § 15-1005.
- Report late-payment frequency and total interest paid by line of business.
- Alabama Comparison: Alabama imposes 1.5% monthly interest, prorated daily, and payable automatically at the time of claim payment. Maryland’s interest requirement would benefit from similar operational clarity.
3. Regulate Virtual Credit Cards and Alternative Payment Methods
- Prohibit default enrollment in fee-based payment mechanisms.
- Require affirmative opt-in and full disclosure of fees without adding to delays in prompt payment when a provider opts for paper payment to eliminate a 1.5 – 2% fee to receive electronic payments, which has been the standard operating practice.
- Clarify that prompt-pay timelines apply regardless of payment modality.
- Virginia has addressed this in regulatory language
4. Standardize Attachment and Documentation Policies
- Require carriers to accept standard electronic attachments at initial submission.
- Publish clear documentation requirements by service type and product line.
5. Strengthen Market Conduct Oversight Through Standardized Data
- Require reporting of clean claim acceptance rates, resubmission rates, late-payment totals, and additional-information request outcomes.
- Use these metrics to inform targeted examinations and corrective action plans.
- Alabama Comparison: Alabama’s statute includes explicit timelines for adjustments, refunds, and recoupments (one-year limit), demonstrating how clear parameters reduce administrative disputes.
- Establish Fair and Ethical Business practices requiring payers to improve transparency on their websites and operationally when contract disputes or concerns need to be communicated from a provider. This includes giving providers the opportunity to negotiate contract rates AND not have payment rates submitted to provided via email or a bulletin, which would support Fairness and Ethical Business practices. Virginia, in 2023, formed the Ethics and Fairness in Carrier Business Practices Work Group to address this concern. The report can be found here.
Delayed clean claims continue to threaten practice stability, patient access, and compliance with Maryland’s Prompt Pay Law. APTAMD respectfully urges MIA to adopt the regulatory updates outlined above — including lessons from Alabama — to ensure timely, accurate, and transparent claim adjudication across all payer types.
We appreciate MIA’s leadership and welcome continued efforts to establish practical, enforceable solutions.
Respectfully submitted,
APTA Maryland
Roy Film, PT, DPT, MPT — President
Zeeshan Bhimani, PT, DPT — Director for Reimbursement
